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MEMORY LOSS
LEARNING OBJECTIVES:
PATHOPHYSIOLOGY:
In the case of memory loss caused by Alzheimer's disease, it is characterised by
loss of neurons and synapses in the cerebral cortex and certain subcortical
regions. This loss results in gross atrophy f the affected regions, including
degeneration in the temporal lobe and parietal lobe. Both amyloid plaques and
neurofibrillary tangles are clearly visible by microscopy in brains of those
afflicted by AD.
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HISTORY:
Important questions to ask include:
1. Can the patient remember recent events, and/or remote events
(events further back in time)?
2. When did the memory problems start?
3. How did the memory problems evolve?
4. Were there any factors which may have caused the memory loss, such
as a head injury, surgery, or stroke?
5. Is there a family history of any neurological or psychiatric diseases or
conditions?
6. Details about the patient's alcohol intake.
7. Is the patient currently on any medication?
8. Has the patient taken illegal drugs, such as cocaine, marijuana, etc.?
9. Are the patient's symptoms undermining his/her ability to look after
himself/herself?
10. Does the patient have a history of depression? Elderly patients with
depressed mood, hopelessness, and suicidality may be suffering from
"pseudodementia" ( false dementia). When the depression is alleviated
with treatment, the dementia-like condition fully resolves.
11. Has the patient ever had cancer? (possibility of brain metastases)
12. Does the patient have a history of seizures?
EXAMINATION:
In the case of acute memory loss, a full neurological exam including fundoscopy
needs to be carried out urgently.
1. Fever: Fever may point to infection, heat illness, thyroid storm, aspirin
toxicity, or the extreme adrenergic overflow of certain drug overdoses
and withdrawal syndromes (in particular, delirium tremens). Extreme
hyperthermia (with pinpoint pupils) may be seen in pontine strokes.
Temperature or neck stiffness may suggest meningitis or subarachnoid
haemorrhage
2. Respiratory Rate: In patients with a rapid respiratory rate, consider
diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant drug
intoxication, and aspirin overdose.
In patients with a slow respiratory rate, consider narcotic overdose, CNS
insult, or various sedative intoxications.
3. Pulse: A rapid pulse rate is seen in patients with fever, sepsis,
dehydration, thyroid storm, and various cardiac dysrhythmias and in
overdoses of stimulants, anticholinergics, quinidine, theophylline,
tricyclic antidepressants, or aspirin. Patients with a slow pulse rate may
have elevated intracranial pressure, asphyxia, or complete heart block.
Calcium channel blockers, digoxin, and beta-blockers also may
produce altered mental status and bradycardia.
4. Fundoscopy: Papilleodema suggests raised intracranial pressure.
5. Focal Neurological Signs: Unilateral limb weakness, facial droop,
dysphasia may indicate recent CVA.
INVESTIGATIONS:
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Bloods:
1. Full blood count and ESR
2. Urea and Electrolytes(U/E), calcium, renal function tests
3. Blood glucose level
4. Liver function tests
5. Thyroid function tests
6. Blood cultures, if fever
7. Syphilis and HIV testing, if appropriate
8. Folic Acid
9. B12 assay for deficiency which may suggest subacute combined
degeneration of spinal cord which in the late stages can cause cognitive
impairment, memory loss and confusion
10. ANA antibody to detect lupus erythematosus
11. Lead levels, if suspected lead poisoning
Urine
Radiological:
1. CT Brain: A CT scan without should be obtained if CNS infection,
trauma, or a cerebral vascular accident (CVA) is suspected. A CT scan is
excellent for detecting acute hematomas and most subarachnoid
hemorrhages (SAH) but is most accurate early in the course. Follow-up
lumbar puncture may be needed to rule out SAH.
2. MRI Brain: An MRI brain may be considered as part of the work up for
dementia as it helps distinguish between Alzheimer disease and vascular
causes of dementia.
Miscellaneous
Cognitive tests.
MMSE Below:
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